Provider Demographics
NPI:1508986076
Name:UNITED CEREBRAL PALSY ASSOCIATION OF PHILADELPHIA & VICINITY
Entity Type:Organization
Organization Name:UNITED CEREBRAL PALSY ASSOCIATION OF PHILADELPHIA & VICINITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIBBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:215-248-7602
Mailing Address - Street 1:102 E MERMAID LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-3507
Mailing Address - Country:US
Mailing Address - Phone:215-242-4200
Mailing Address - Fax:215-247-4229
Practice Address - Street 1:102 E MERMAID LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-3507
Practice Address - Country:US
Practice Address - Phone:215-242-4200
Practice Address - Fax:215-247-4229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA139930251S00000X
PA171040251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251S00000XAgenciesCommunity/Behavioral Health
Not Answered251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000015100012Medicaid